87-3016 - Laserfiche WebLink

Home Browse Search

h APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA I Telephone (209) 466-6781, yr PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .'(Complete iri_,Triplicate) { Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County.Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ,c "s Job Address 3�Q { City Lot Sire r y Owner's Name AddressIR Z Phone I Contractor' ^ !�' Address License No. Phone TYPE OF WELL/PUMP: NEW-WE r w WELL El-REPLACEMENT DESTRUCTION { PUMP I'IVSTALLATION`❑ '- SYSTEM REPAIR'❑"'"-„ OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINEA ✓ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEATIO 5 .. ❑ Industrial Open Bottom ❑ Manteca Dia, of Well Excavati��: Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ` f Specifications rS Public ❑ Ot er ❑ Delta I Depth.of Grout Seal Type of Grout (� ❑ Irrigation ____Approx. Depth ❑ Eastern z dJ P Surface Seal_Installed_by._. .� # ! .Repair Work Done ❑ Type of Pump H.P. ' State Work Done L,* Well Destruction ❑ Well Diameter Sealing Material (top 501) r Depth Filter Material (Below 501) t i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAfR/ADDITION ❑ DESTRUCTION ❑ (No septic within 200 feet.) system permit available ted if public sewer is Installation will serve: Residence� Commercial, Other � Number of living units: �!,Number of bedrooms r Character of soil to a depth-of 3Meet: . Water table depth T SEPTIC—TANK ❑� } ` %—ype/Mfja :- CapacityNo. Compartments PKG. TREATMENT PLT. ❑ "�" i 1 � , � ' .. Method,of Disposal Distance to nearest_: Well Foundation Property Line , LEACHING LINEy ❑ No.-& Length of lines k tt s Total length/size irv"t. FILTER BED a �+s r C7. 4 Distance to nearest: Well Foundation ', ^i ' I [ Property Line, L SEEPAGE PITS r ❑ Depth Size Lj Number ' SUMPS ;� r ❑ Distance to nearest: Well Foundation F, _ ' Property Line ' DISPOSAL PONDS ❑ t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Paws, and rules and regulations of the San Joaquin Local Health District. -��- .- Home owner or licensed agent's signature certifies the following: "I cert 7 in the performance of the work for which this permit is issued, I shall ril employ any person in such manner a_s to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature r0 certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ L tion laws of.California." P Y persons subject to workman's compensa I ' r The applicant mu call for all r quired inspectiansComplete drawing-on reverse side. ri Signed Title: k t t'�; 'W ..-.�.. - Date: FO� KPAIITMENT USE ONLY I a. Application Accepted by s , Area t 7 Pit or Grout Inspection by Date Final Inspection by {337 € Date ; A ditional Comments. . { Stk 4684781—O-Lodi—369 ❑ Manteca 823-' 04 Q TracyVkp �83rrF $5 plicant- Return all copies to: Environmental Health Permit ° i /Services 1 E Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ".`"__ FEE . -— _ AMOUNT DUE AMOUNT RE" IT'ED,I T INFO CASH' RECEIVED BY DATE PERMIT�NO. +'EH 13.241REV.1/651 1,� � Ek 10.26 ✓��1